Provider Demographics
NPI:1902919376
Name:GILLOON, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:GILLOON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 HIGHWAY 36 W STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-292-0000
Mailing Address - Fax:
Practice Address - Street 1:2355 HIGHWAY 36 W STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3905
Practice Address - Country:US
Practice Address - Phone:651-292-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI554482085R0202X
MN552912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology